Maryland Primary Care Program COVID-19 Telehealth Billing ... · CPT coding changes impacting the...

COVID-19

Telehealth

Billing & Coding Guidelines

April 9, 2020

Presented by:

Marie Pelino, CPC, Senior ConsultantRosen, Sapperstein & Friedlander, LLC.

Health Care Division

Rosen, Sapperstein & Friedlander, LLC130 Admiral Cochrane Drive, Suite 102

Annapolis, MD 21401410-581-0800

www.rsandf.com

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Maryland Primary Care Program

ROSEN, SAPPERSTEIN & FRIEDLANDER, LLC HEALTH CARE DIVISION

http://www.rsandf.com/

Agenda for TodayApril 9, 2020

Rosen, Sapperstein & Friedlander, LLC Health Care Division

Introduction

MDH Updates.

RS&F Introduction.

2020 CPT Changes Impacting the MDPCP Billing Resource Manual

Health Behavior Assessment & Intervention.

Technology-Based Services.

COVID-19 Expanded Telehealth Coverage

Questions & Answers

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Maryland Department of Health Maryland Primary Care Program Billing

Resource Guide


MDPCP Billing and Coding Manual

Reference Guide: How to View the Document

Maryland Localities

https://health.maryland.gov/Pages/programs.aspx

https://linkprotect.cudasvc.com/url?a=https://health.maryland.gov/mdpcp/Documents/MDH%20MDPCP%20Billing%20Resource%20Guide%20Sept.%202019%20FINAL.pdf&c=E,1,6kPSotyLV9Y7YiSnjoizBQTQM_P8ls06Vk-S1nbnyaQrdaUa_TqjMLab3yTNxO-CUcrO2A-2CHBaJAPqrBJzK-dTzpUEh0wR5aZ40-OmQw,,&typo=1

https://linkprotect.cudasvc.com/url?a=https://health.maryland.gov/mdpcp/Documents/MDPCP%20Billing%20Reference%20Guide%20How%20to%20View%20the%20Document%20in%20Adobe.pdf&c=E,1,5-tvTzA5EpCJFXAxxCbSZnojkSxd6rdLDUhrnHytaI7IF5OCO2H-EnAfRjvv0GToOcWGRZAzapKYtejmm6859ERiElLBGUbOEs1Hi0kg5OATcsdP2sazVg,,&typo=1

https://linkprotect.cudasvc.com/url?a=https://health.maryland.gov/mdpcp/Documents/Localities%20MD.pdf&c=E,1,uvAsWM_vNKVjNQeawm4OfDCCBW6YygGAQ0jH5ZoI_tJFndQW3LrwLRmlFMGdtHrE74dv-4dVmaxEAy_jKVugEBSiqE_e17X0TC3f3t7uxxt6U6eoc04,&typo=1

https://health.maryland.gov/Pages/programs.aspx

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CPT codes are revised annually to delete existing codes, add new codes, revise descriptions to active codes.

CPT coding changes impacting the current Billing Guide for MDPCP are confined to 2 sections:

Health Behavior Assessment & Intervention.

Technology-Based Services.

CPT Coding Changes Effective January 1, 2020


ROSEN, SAPPERSTEIN & FRIEDLANDER, LLC HEALTH CARE DIVISION 5

CPT deleted all HBI codes in 2019 & re-assigned new codes.

Health behavior assessment is no longer time based.

Increased the minimum amount of time required to report the service.

Added codes to report additional time in 15 minute increments if performed.

HBI codes are payable to Clinical Psychologists under Medicare.

MD/DO/NP’s should bill this service using E/M codes based on time.

Health Behavior Assessment & Intervention

Effective January 1, 2020


Code Description Telehealth Eligible

Maryland JurisdictionsMD Medicaid

FeeLicensure of Rendering

ProviderCommercial

Payers CrosswalkBaltimore Counties DC Suburbs Rest of MD

Health Behavior Interventions - Health and behavior assessment and/or intervention services performed by a QHCP other than a clinical psychologist must be reported with the appropriate Evaluation and Management (E/M) codes.

G0447 Face-to-face behavioral counseling for obesity, 15 minutes √ $ 27.86 $ 29.17 $ 26.84 MD/DO NP/PA or RD's

under Incident to 99401

96156Health behavior assessment, or re-assessment (i.e., health-focused clinical interview, behavioral observations, clinical decision making) * $ 104.91 $ 109.21 $ 101.71 $ 27.25 Clinical Psychologist

96158Health behavior intervention, individual, face-to-face; initial 30 minutes

$ 71.46 $ 74.38 $ 69.36 Clinical Psychologist

96159Health behavior intervention, individual, face-to-face; each additional 15 minutes (List separately in addition to code for primary service)

* $ 24.99 $ 26.02 $ 24.33 NC Clinical Psychologist

96164Health behavior intervention, group (2 or more patients), face-to-face; initial 30 minutes * $ 10.62 $ 11.05 $ 10.28 NC Clinical Psychologist

96165Health behavior intervention, group (2 or more patients), face-to-face; each additional 15 minutes (List separately in addition to code for primary service)


96167Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes * $ 76.81 $ 79.95 $ 74.52 NC Clinical Psychologist

96168Health behavior intervention, family (with the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service)


96170Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes

$ 87.99 $ 92.26 $ 84.72 NC Clinical Psychologist

96171Health behavior intervention, family (without the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service)

$ 32.23 $ 33.76 $ 30.96 NC Clinical Psychologist

* Health behavior assessment & intervention services were added back to the list of CMS covered telemedicine services in the wake of COVID-19 response.

Health Behavior Assessment & Interventions

Effective January 1, 2020

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REMOTE PATIENT MONITORING REVISION AND ADDITIONS TO CPT

CPT revised the description for Remote Physiologic Monitoring 99457 to report the first 20 minutes in a calendar month.

CPT added an additional code 99458 to report each additional 20 minutes in a calendar month.

CPT added 2 new codes 99473 to report calibration of a patient’s home blood pressure monitoring device AND 99474 to report daily review of BP patient collected data and treatment plan revision/maintenance.

Technology-Based ServicesEffective January 1, 2020



Technology-Based ServicesEffective January 1, 2020

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Effective March 1, 2020 and throughout the duration of the COVID-19 Public Health Emergency (PHE):

Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings.

Medicare will consider telehealth services same as in-person services & paid at the same rate.

No costly technology required: o HHS authorizes the use of telephones that have

audio & video capabilities for the furnishing of Medicare telehealth services.

Patient Cost-Share Waiver: o Co-insurance & deductibles will be applied to

telehealth services. The OIG is providing flexibility for providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Expanded Telehealth Coverage


ROSEN, SAPPERSTEIN & FRIEDLANDER, LLCHEALTH CARE DIVISION 10

Three (3) Types of Virtual Visits

Type of ServiceMethod of

CommunicationsService Description

Telemedicine Evaluation & Management

Services

Real-time telephone & video communication devices through HIPAA

compliant vendor or acceptable

smartphone/tablet technology.

Medically necessary E/M services to diagnose and/or

treat general health conditions that would normally be covered if

rendered during a face-to-face visit.

Virtual Check-in is Telephone

OnlyTelephone Calls

Audio Only

G2012 or 99441 5-10 min.99442 11-20 min. 99443 21-30 min.

E-Visits/Online Digital

Evaluations

Asynchronous Communication

through a Patient Portal

Time is cumulative during a7 day period.

99421 5-10 min. 99422 11-20 min. 99423 21-30 min.

G2010 – Brief digital check-in


The Office of Civil Rights (OCR) recommends that providers prepare to use HIPAA-compliant vendors following the COVID-19 PHE, such as:

Skype for Business/Microsoft Teams.

Updox.

Vsee.

Zoom for Healthcare.

Doxy.me.

Google G Suite Hangout Meet.

Cisco WebEx Meetings/WebEx Teams.

Amazon Chime.

GoToMeeting.

Telemedicine Visits – HIPPA Compliant Vendors

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HIPAA enforcement is temporarily waived during the PHEAcceptable Platforms (State of Emergency Only)

• Apple Facetime

• Google G-suite Hangouts

• Skype for Business

• Zoom

Unacceptable Platforms

• Facebook Live

• TikTok

• Twitch

• Public facing applications

Telemedicine Visits - Require Audio-Visual


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CPT CODES 99201-99215

E/M documentation MUST meet CPT criteria guidelines relative to the level of documented:

History.

Exam.

Medical decision making.

Documentation must include:

Telecommunication platform.

Patient consent to care.

Office/Outpatient Department Visits



EDLANDER, LLC HEALTH CARE DIVISION

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Clinicians may base the E/M service level on:

Medical Decision Making (MDM) Only.

OR Time:

o Time is defined as “all of the time” associated with the E/M on the day of the encounter.

o Concept of time is aligned with E/M criteria changes effective January 1, 2021

o Durations for levels are the "typical time" associated with the E/M code.

Medicare Rule Changes During PHE

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99201 - 10 min.

99202 - 20 min.

99203 - 30 min.

99204 - 45 min.

99205 - 60 min.

99211 - 5 min. – Can be a Nurse visit

99212 - 10 min.

99213 - 15 min.

99214 - 25 min.

99215 - 40 min.

Documentation: Document the total time spent on the encounter on the

day of the encounter.

Count time spend in record review & documentation of the encounter.

“Total duration of this encounter was 25 minutes”.

Office/Outpatient Department Visits Time-Based Levels


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99241-99349 CPT codes added to the telemedicine list of codes in light of the COVID-19 emergency.

Document that the Telemedicine visit is taking the place of the scheduled home visit (home bound patient).

Services must meet criteria established by CPT guidelines OR the revised E/M selection criteria (MDM vs total time).

99341 Home visit; new patient - 20 min.





99347 Home visit; est. patient - 15 min.




Home Visits Time-Based Levels


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Documentation requirements include: Health Risk Assessment.

Past Medical History.

Written plan of preventive services.

If patient is unable to report their weight or blood pressure from a

home monitoring device, document the presence of any

associated risk factors relative to weight & blood pressure &

address accordingly.

Preventive Services/AWV’s


G0438 Initial AWV/Personal prevention plan service.

G0439 Subsequent AWV/Personal prevention plan service visit.

G0442 Annual alcohol screen 15 min.

G0443 Brief alcohol misuse counsel.

G0444 Depression screen annual.

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99495 - Transitional Care Management Services (TCM) with the following required elements:

Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.

Medical decision making of at least moderate complexity during the service period.

Face-to-face visit (this component must be a telemedicine audio-visual visit), within 14 calendar days of discharge.

99496 - Transitional Care Management Services (TCM) with the following required elements:

Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.

Medical decision making of high complexity during the service period.

Face-to-face visit (this component must be a telemedicine audio-visual visit), within 7 calendar days of discharge.

Transitional Care Management


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Critical Planning during a PHE99497 - Advance care planning including the explanation & discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

99498 - Advance care planning including the explanation & discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Providers should document:

Time.

Summary of discussion.

Participants.

Report POS 11 for full non-facility rate of reimbursement.

Advanced Care Planning


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Billing Medicare for TelemedicineServices Interim Coding Rules

When submitting claims for telemedicine services with dates-of- service on or after March 1, 2020, and for the duration of the PHE, report:

Place of Service (POS) equal to what it would have been in the absence of a PHE.

Append modifier 95 to CPT codes, indicating that the service rendered was actually performed via interactive audio video.

This is a change announced on 03/31/2020 that is applicable 03/01/20 & applies to E/M services provided via audio/visual during pandemic period.


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CMS Interim Rules Effective 03/01/2020Telephone Evaluation & Management

(E/M) Services

Prior CMS Non-Coverage for Non-Face-to-Face Services• In CY 2008, the CPT Editorial Panel created CPT

99441-99443 codes to describe E/M services furnished by a physician or qualified healthcare professional via telephone.

• CMS assigned a status indicator of “N” (Non-covered) to these services because:

(1) These services are non-face-to-face; and

(2) the code descriptors include language that recognizes t the provision of services to parties other than the beneficiary for whom Medicare does not provide coverage (for example, a guardian).

• CMS now believes they should be covered in light of the COVID-19 emergency.


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•Virtual Check in G2012- 5-10 min. “established in 2017 as a covered service”.

Added codes to the MPFS due to the PHE:

•99441 Telephone E/M new or established 5-10 min. MCR allowance $15.34



Medicare does not consider these services to fullyreplace a telemedicine E/M visit. These codes should bereported when the E/M is sufficient to warrant a separateservice unrelated to coordination of care following anE/M in the previous 7 days.

• Do not use POS 02 or modifier 95 with these.

Billable Telephone/Audio Only Services


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• These services apply to new & established patients during the PHE.

• These services should be patient initiated however, the provider may contact the patient to educate them that the service is available.

• The service requires the patient consent for billing.

•Do not report 99441-99443 during the time period when billing for Transitional Care Management.

•Home and Outpatient INR monitoring reported as 93792, 93793 were not designated as a telemedicine visit but can be replaced by the telephone visit if documented appropriately.

Other Considerations for Telephone E/M: CODES 99441 - 99443 & G2012


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•Virtual Check-in G2010 –Store and Forward technology utilizing recorded video or image forwarded to provider

•Digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days

•99421 Online digital E/M new or established 5-10 min. MCR allowance $16.52



Document cumulated time during a 7 day period where asynchronous secure messaging or recordings was the means to evaluate and manage a health condition or problem.

• Do not use POS 02 or modifier 95 with these.

Billable Online/Digital Only Services


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Providers can now:

•Bill for additional types of televideo visits at the same rate as in-person visits.

•Emergency department visits, initial nursing facility and discharge visits, home visits, and therapy services, which must be provided by a clinician that is allowed to provide telehealth.

Medicare now allows telemedicine to fulfill many face-to-face visit requirements for clinicians to see their patients in inpatient rehabilitation facilities, hospice & home health.

For a complete list of Telehealth services that can be reported as in person using a synchronous acceptable telecommunication platform :https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

Additional Telehealth Provisions


https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

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Additional Waivers

To better serve the patient population that would otherwise not have access to clinically appropriate in-person treatment, the following services no longer have limitations on the number of times they can be provided by Medicare telehealth:

No limit to the number of medically necessary telemedicine E/M services.

A subsequent inpatient visit can be furnished more frequently than every 3 days (CPT codes 99231-99233)

A subsequent skilled nursing facility visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 30 days (CPT codes 99307-99310)

For services requiring direct supervision by the physician or other practitioner, that physician supervision can be provided virtually using real-time audio/video technology.


Removal of Frequency Limitations on Medicare Telehealth

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Providers must maintain documentation in the same manner as for an in-person visit or consultation, using either electronic or paper medical records.

The provider should document the participant’s consent to receive telehealth services in their medical record.

Consent may be given verbally by the participant.

Consent need only be given once per year.

Documentation Guidelines


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Medicare provides coverage of laboratory testing without costs-sharing (87635)

Medicare provides coverage of E/M services that result in an order for or administration of a COVID-19 test (87635)

Append modifier CS to the CPT codes reporting EM services resulting in the order or administration of a COVID-19 test.

Treatment of COVID-19 and associated respiratory disease will be subject to deductibles & co-insurance.


Medicare Coverage of C0VID-19 Testing and Related Encounters

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Z03.818 Encounter for observation for suspected exposure to other biological agents ruled out.

Z20.828 Contact with & (suspected) exposure to other viral communicable diseases.

Z71.84 Encounter for health counseling related to travel (Health risk & safety counseling).

Z71.1 Person with feared health complaint in whom no diagnosis is made.

U07.1 COVID-19 (confirmed test) effective 4/1/20

COVID-19 Related ICD-10 Codes


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For patients presenting with any signs/symptoms (such as fever, etc.) & where a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms first:

R05 Cough.

R06.02 Shortness of breath.

R50.9 Fever, unspecified.

J12.89 Other viral pneumonia.

J20.8 Acute bronchitis due to other specified

organisms.

J22 Unspecified acute lower respiratory infection.

COVID-19 Related Presenting Problems ICD-10



Revised 4-2-20

Service Descriptions & Codes

CareFirst United Health Care Aetna Cigna Medicaid/MCO's

Office visits via synchronous interactive audio visual communication devices HIPAA compliant now includes Apple Facetime, Google G Suite Hangouts Meet & Skype) CPT codes 99201-99215

Report E/M CPT code with POS code 02 & Modifier 95

Report E/M CPT code with POS code 02 & Modifier 95(Exception *Telephone audio only is now allowed by UHC)

Report E/M CPT code with POS code 02 & Modifier 95

Report E/M CPT code with POS code 11 & Modifier GQ (Exception *Telephone audio only is now allowed by Cigna)

Report E/M CPT code with POS code 11 & Modifier GT

Telephone evaluation & management (E/M) (Audio only) calls based on time 99441-99443 (New or Established patients) 'Virtual Check-in'

Carefirst will allow 99441-99443 & pay a flat fee of $20.00

Report only G2012 with POS 11 & NO Modifier.

Report CPT code with POS 11 with NO modifier. Report G2012 for Medicare Advantage plans.

Report G2012 onlywith POS 11 & NO Modifier for brief check in-phone calls. Telephone E/M's should be reported as interactive telemedicine.

Audio only E/M may only be reported with CPT 99211, 99212 or 99213 with POS 11 & Modifier UB

Cost-Sharing to the Patient Non-specific policy cost-sharing policy. CF directs provider not to collect copays during the PHE. Balance-billing is permitted after claims processed.

No Patient cost-sharing during the PHE. Network rates paid in full but may vary by plan.



No Patient cost-sharing during the state of emergency

Telemedicine, Telephone & Online Digital E/M Service Billing Guide

Resourceshttps://individual.carefirst.com/individuals-families/about-us/coronavirus-healthcare-providers.page

www.uhcprovider.com/en/resource-library/news/provider-telehealth-policies.html

https://www.aetna.com/health-care-professionals/provider-education-manuals/covid-faq.html#acc_link_content_section_responsivegrid_copy__responsivegrid_accordion_10

https://static.cigna.com/assets/chcp/resourceLibrary/medicalResourcesList/medicalDoingBusinessWithCigna/medicalDbwcCOVID-19.html

https://mmcp.health.maryland.gov/Pages/telehealth.aspx

https://individual.carefirst.com/individuals-families/about-us/coronavirus-healthcare-providers.page

http://www.uhcprovider.com/en/resource-library/news/provider-telehealth-policies.html

https://www.aetna.com/health-care-professionals/provider-education-manuals/covid-faq.html

https://static.cigna.com/assets/chcp/resourceLibrary/medicalResourcesList/medicalDoingBusinessWithCigna/medicalDbwcCOVID-19.html

https://mmcp.health.maryland.gov/Pages/telehealth.aspx

32ROSEN, SAPPERSTEIN & FRIEDLANDER, LLC HEALTH CARE DIVISION

https://www.aapc.com/resources/free-tools/provider-manual/

Payor Specific Resources

https://www.aapc.com/resources/free-tools/provider-manual/

American Telemedicine.orgAmerican Academy of Pediatricshttps://www.aap.org/en-us/Documents/coding_factsheet_telemedi cine.pdfCenters for Medicare and Medicaid Services https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf

Information/Resources


AAFPhttps://www.aafp.org/patient-care/emergency/2019-coronavirus/telehealth.html

CMS General Provider Telehealth & Telemedicine Tool Kit:https://www.cms.gov/files/document/general-telemedicine-toolkit.pdf

AMA Telemedicine Quick Set-up Guide: https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice

Expansion of Telehealth & Licensing Waivers During Pandemic:http://connectwithcare.org/state-telehealth-and-licensure-expansion-covid-19-chart/

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https://www.aap.org/en-us/Documents/coding_factsheet_telemedi%20cine.pdf

https://www.aafp.org/patient-care/emergency/2019-coronavirus/telehealth.html

https://www.cms.gov/files/document/general-telemedicine-toolkit.pdf

http://r20.rs6.net/tn.jsp?f=001kgiZuE8YDkkO2P4AYfI_r--EqV5j2-G_7XQXKyoqNErr4f1nIq1WkAIruKEkJ_hYzduvrpA5HJpITrABrc7tXHw-PQNUVG2H85z2tzdsOZAF6mWJWAgTpA1r9m6s-dnnS39YI5tun00X3kdj4WOMdJtv-4e31j964fbjSU1BVAHWSjiI9_wSuTiF5N6OEgo1sR6zcd9bp8qNNrh2ZCPSVUmC6cvcJOiIQ3iNXKP3Fbk=&c=vdEEfeK93S7jTZsF1xs9LjAXBP_d6gihXl0dpCDMrwXo22i2_NvA6g==&ch=IRQ-HJIfc8r51y0oaeRqN3Yv56-pVNwZCr3nSESk87pWJdqwIO39rg==

http://connectwithcare.org/state-telehealth-and-licensure-expansion-covid-19-chart/


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